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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022https:\/\/bjo.bmj.com\/sites\/default\/files\/advagg_css\/css__ZqR9oFtEjI7t5h7UPJpE0tHpaVSMTAbm0a23YsPXKOs__z0ziYHnUeoonPnsQckGJK26VB3Dp5GbBJ1xzkT0Vnb0__FJkwznkQkAcnbD9WjMiQCFEmfBzUt7MwRmtNmF6qFjE.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-jnl-template-bmjj-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup author-affiliates col-narrow-12 author-affiliates-corresp article\u0022 \u003E\n \n \n \n \u003Cdiv class=\u0022pane-content\u0022\u003E\n \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 class=\u0022contributors\u0022\u003E\u003Col class=\u0022contributor-list\u0022 id=\u0022contrib-group-1\u0022\u003E\u003Cli id=\u0022contrib-1\u0022\u003E\u003Cspan class=\u0022name\u0022\u003EJuntaro Sugita\u003C\/span\u003E, \u003C\/li\u003E\u003Cli id=\u0022contrib-2\u0022\u003E\u003Cspan class=\u0022name\u0022\u003EJunko Kondo\u003C\/span\u003E\u003C\/li\u003E\u003C\/ol\u003E\u003Col class=\u0022affiliation-list\u0022\u003E\u003Cli class=\u0022aff\u0022\u003E\u003Ca id=\u0022aff-1\u0022 name=\u0022aff-1\u0022\u003E\u003C\/a\u003E\u003Caddress\u003ESugita Eye Hospital, Nagoya, Japan\u003C\/address\u003E\u003C\/li\u003E\u003C\/ol\u003E\u003Col class=\u0022corresp-list\u0022\u003E\u003Cli class=\u0022corresp\u0022 id=\u0022corresp-1\u0022\u003E\u003Cspan class=\u0022corresp-label\u0022\u003E\u003C\/span\u003EJuntaro Sugita, MD, Sugita Eye Hospital, 5\u20131\u201330 Sakae, Naka-ku, Nagoya 460, Japan.\u003C\/li\u003E\u003C\/ol\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E \u003C\/div\u003E\n\n \n \u003C\/div\u003E\n\u003Cdiv class=\u0022panel-separator\u0022\u003E\u003C\/div\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n \n \n \n \u003Cdiv class=\u0022pane-content\u0022\u003E\n \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article abstract-view\u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003EAbstract\u003C\/h2\u003E\n\n\n\u003Cp id=\u0022p-1\u0022\u003E\u003Cstrong\u003EAIMS\/BACKGROUND\u003C\/strong\u003E Deep lamellar keratoplasty (DLK) was performed to restore visual acuity in 120 eyes with corneal stromal opacification. DLK is believed to be an effective treatment in eyes in which endothelial cell function had been preserved, and in which there was no epithelial or stromal oedema. The purpose of this study was to evaluate the effectiveness of this treatment.\u003C\/p\u003E\n\n\n\n\u003Cp id=\u0022p-2\u0022\u003E\u003Cstrong\u003EMETHODS\u003C\/strong\u003E The stroma was excised to the extent that only Descemet\u2019s membrane remained, at least in the optical zone. Donor corneas of full, or almost full, thickness with Descemet\u2019s membrane removed, or which had been lathed to a thickness of 0.4 mm from the endothelial side, were attached by suturing.\u003C\/p\u003E\n\n\n\n\u003Cp id=\u0022p-3\u0022\u003E\u003Cstrong\u003ERESULTS\u003C\/strong\u003E In 113 eyes which were observed for 6 months or more postoperatively in which average prospective visual acuity was 0.09, average postoperative visual acuity improved to 0.6. Specular microscopy 1 month postoperatively revealed average endothelial cell counts of 2225 (SD 659)\/mm\u003Csup\u003E2\u003C\/sup\u003E, while 24 months postoperatively this value was 1937 (642)\/mm\u003Csup\u003E2\u003C\/sup\u003E (cell loss 13%). Puncturing of Descemet\u2019s membrane during surgery occurred in 47 of 120 eyes (39.2%), but after 12 months, there was no difference in visual acuity or number of endothelial cells between these eyes and those in which no puncturing had occurred.\u003C\/p\u003E\n\n\n\n\u003Cp id=\u0022p-4\u0022\u003E\u003Cstrong\u003ECONCLUSIONS\u003C\/strong\u003E There was no postoperative endothelial rejection reaction with DLK, and restoration of postoperative visual acuity was quite adequate. Compared with penetrating keratoplasty, DLK allows endothelial cell counts to be maintained for a longer period. 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class=\u0022panel-separator\u0022\u003E\u003C\/div\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n \n \n \n \u003Cdiv class=\u0022pane-content\u0022\u003E\n \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view\u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003E\u003Ca href=\u0022\/search\/%20text_abstract_title%3Adeep%2Blamellar%2Bkeratoplasty%20text_abstract_title_flags%3Amatch-phrase%20sort%3Apublication-date\u0022 class=\u0022hw-term hw-article-keyword hw-article-keyword-deep-lamellar-keratoplasty\u0022 rel=\u0022nofollow\u0022\u003Edeep lamellar keratoplasty\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003E\u003Ca href=\u0022\/search\/%20text_abstract_title%3Aoptical%2Bkeratoplasty%20text_abstract_title_flags%3Amatch-phrase%20sort%3Apublication-date\u0022 class=\u0022hw-term hw-article-keyword hw-article-keyword-optical-keratoplasty\u0022 rel=\u0022nofollow\u0022\u003Eoptical keratoplasty\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003E\u003Ca href=\u0022\/keyword\/descemet%E2%80%99s-membrane\u0022 class=\u0022hw-term hw-article-keyword hw-article-keyword-descemet\u0026#x2019;s-membrane\u0022 rel=\u0022nofollow\u0022\u003EDescemet\u2019s membrane\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003E\u003Ca href=\u0022\/search\/%20text_abstract_title%3Ahydrodelamination.%20text_abstract_title_flags%3Amatch-phrase%20sort%3Apublication-date\u0022 class=\u0022hw-term hw-article-keyword hw-article-keyword-hydrodelamination\u0022 rel=\u0022nofollow\u0022\u003Ehydrodelamination.\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-5\u0022\u003ELamellar keratoplasty (LKP) is regarded mainly as a technique of therapeutic keratoplasty, as restoration of visual acuity postoperatively is often poor with this procedure. However, deep lamellar keratoplasty (DLK), in which pathological corneal stroma is completely excised as far as Descemet\u2019s membrane, at least in the pupillary region, leads to a marked improvement in postoperative visual acuity, and compares favourably with penetrating keratoplasty (PKP). DLK is indicated for eyes in which there is stromal opacification with no epithelial or stromal oedema, and where it is thought that endothelial cell function is preserved.\u003C\/p\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-5\u0022\u003E\n\u003Ch2\u003EMaterials and methods\u003C\/h2\u003E\n\u003Cp id=\u0022p-6\u0022\u003EDLK was performed at the Sugita Eye Hospital in 120 eyes in 106 patients over the period May 1988 to April 1995. Preoperative diagnoses were corneal leucoma in 47 eyes in 40 patients, lattice corneal dystrophy in 22 eyes in 20 patients, gelatinous drop-like dystrophy in 22 eyes in 19 patients, granular corneal dystrophy in seven eyes in five patients, scarring after infections including corneal herpes in 18 eyes in 18 patients, and four eyes in four patients otherwise.\u003C\/p\u003E\n\u003Cp id=\u0022p-7\u0022\u003EWith the exception of one patient, there was no corneal epithelial or stromal oedema. In all patients preoperative ultrasound pachymetry revealed that the minimum corneal thickness was no more than 620 \u03bcm.\u003C\/p\u003E\n\u003Cp id=\u0022p-8\u0022\u003EAges of patients ranged from 8 to 86 years (average age 59 years). There were 50 male and 56 female patients. Donor corneas used were full thickness corneas including endothelial cells in 16 eyes, corneas in which Descemet\u2019s membrane had been ablated with a cotton swab in 50 eyes, and corneas lathed to a thickness of about 0.4 mm from the endothelial side by using Barraque\u2019s cryolathe in 54 eyes.\u003C\/p\u003E\n\n\u003Ch3\u003ESURGICAL METHODS\u003C\/h3\u003E\n\n\u003Ch4\u003ELamellar keratectomy\u003C\/h4\u003E\n\u003Cp id=\u0022p-9\u0022\u003EFirstly, the cornea is trephined through three quarters of its depth and a lamellar keratectomy performed. A trephine with a stopper may be used, but it may be difficult to cut to the desired depth. The Barron vacuum trephine cuts well and is very convenient. However because the edge of the blade is screwed down, depth may vary depending on position.\u003C\/p\u003E\n\u003Cp id=\u0022p-10\u0022\u003EA Golf or Paufique knife is used for the lamellar keratectomy, care being taken to maintain a consistent depth as far as possible. When the fragments of stroma are lifted away, there will be an area of whiteness at the edge of the incision, which is the result of air penetrating between the collagen fibres. The cut is made with the blade moving as if stroking this area.\u003C\/p\u003E\n\n\n\u003Ch4\u003EDeep lamellar keratectomy\u003C\/h4\u003E\n\u003Cp id=\u0022p-11\u0022\u003E\n\u003Cem\u003E(a) Hydrodelamination\u003C\/em\u003E\u2003Stromal collagen fibres are cut across and down to produce a depression, and a saline solution injected with a blunt, 27 gauge needle at the bottom of this depression. The solution penetrates between the collagen fibres, which whiten and swell. Stroma that was not apparent will swell up and can be safely removed by further spatula delamination.\u003C\/p\u003E\n\u003Cp id=\u0022p-12\u0022\u003EBy performing hydrodelamination in this way it is also possible to tell whether or not the remaining stroma is close to normal. Thus, as illustrated in Figure \u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003E1\u003C\/a\u003E, the solution injected spreads evenly in all directions, indicating that the normal structure of the collagen fibres is maintained. With pathological stroma, the solution does not spread evenly and there is little swelling. Because the deeper stromal fibres are coarser, the solution from a single injection will spread more widely. Where the stroma is close to normal, hydrodelamination proceeds until no more swelling can be seen, and removal of the stroma then stops. With pathological stroma, however, excision must proceed until Descemet\u2019s membrane is exposed.\u003C\/p\u003E\n\u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022https:\/\/bjo.bmj.com\/content\/bjophthalmol\/81\/3\/184\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Hydrodelamination. A solution injected into the normal stroma spreads evenly in all directions and the remaining stroma whiten and swell.\u0022 class=\u0022highwire-fragment fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-1095093156\u0022 data-figure-caption=\u0022\u0026lt;div class=\u0026quot;highwire-markup\u0026quot;\u0026gt;Hydrodelamination. A solution injected into the normal stroma spreads evenly in all directions and the remaining stroma whiten and swell.\u0026lt;\/div\u0026gt;\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cspan class=\u0022hw-responsive-img\u0022\u003E\u003Cimg class=\u0022highwire-fragment fragment-image lazyload\u0022 alt=\u0022Figure 1\u0022 src=\u0022data:image\/gif;base64,R0lGODlhAQABAIAAAAAAAP\/\/\/yH5BAEAAAAALAAAAAABAAEAAAIBRAA7\u0022 data-src=\u0022https:\/\/bjo.bmj.com\/content\/bjophthalmol\/81\/3\/184\/F1.medium.gif\u0022 width=\u0022440\u0022 height=\u0022288\u0022\/\u003E\u003Cnoscript\u003E\u003Cimg class=\u0022highwire-fragment fragment-image\u0022 alt=\u0022Figure 1\u0022 src=\u0022https:\/\/bjo.bmj.com\/content\/bjophthalmol\/81\/3\/184\/F1.medium.gif\u0022 width=\u0022440\u0022 height=\u0022288\u0022\/\u003E\u003C\/noscript\u003E\u003C\/span\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u0022download-fig first\u0022\u003E\u003Ca href=\u0022https:\/\/bjo.bmj.com\/content\/bjophthalmol\/81\/3\/184\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\n\u003Cli class=\u0022new-tab\u0022\u003E\u003Ca href=\u0022https:\/\/bjo.bmj.com\/content\/bjophthalmol\/81\/3\/184\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\n\u003Cli class=\u0022download-ppt last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/159801\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\n\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1\u003C\/span\u003E \n\u003Cp id=\u0022p-13\u0022 class=\u0022first-child\u0022\u003EHydrodelamination. A solution injected into the normal stroma spreads evenly in all directions and the remaining stroma whiten and swell.\u003C\/p\u003E\n\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n\u003Cp id=\u0022p-14\u0022\u003E\n\u003Cem\u003E(b) Spatula delamination\u2003\u003C\/em\u003EA small cut is made in the remaining stroma with the Golf knife as if checking the depth, and from the bottom of the cut a fine spatula with a diameter of 0.25 mm (Katena K3\u20132310) is inserted rectilinearly into the stroma.\u003C\/p\u003E\n\u003Cp id=\u0022p-15\u0022\u003EOnce the spatula has advanced some way, it comes back and is moved again and again fan-like in different directions (Fig \u003Ca id=\u0022xref-fig-2-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F2\u0022\u003E2\u003C\/a\u003E). The Paufique knife or corneal scissors is slipped into this opening and the stroma removed. It is important to excise the stroma little by little to avoid going too deep at any point.\u003C\/p\u003E\n\u003Cdiv id=\u0022F2\u0022 class=\u0022fig pos-float\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022https:\/\/bjo.bmj.com\/content\/bjophthalmol\/81\/3\/184\/F2.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Spatula delamination. A fine spatula inserts rectilinearly into the hydrodelaminated stroma and comes back and is moved again and again fan-like in different directions.\u0022 class=\u0022highwire-fragment fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-1095093156\u0022 data-figure-caption=\u0022\u0026lt;div class=\u0026quot;highwire-markup\u0026quot;\u0026gt;Spatula delamination. A fine spatula inserts rectilinearly into the hydrodelaminated stroma and comes back and is moved again and again fan-like in different directions.\u0026lt;\/div\u0026gt;\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cspan class=\u0022hw-responsive-img\u0022\u003E\u003Cimg class=\u0022highwire-fragment fragment-image lazyload\u0022 alt=\u0022Figure 2\u0022 src=\u0022data:image\/gif;base64,R0lGODlhAQABAIAAAAAAAP\/\/\/yH5BAEAAAAALAAAAAABAAEAAAIBRAA7\u0022 data-src=\u0022https:\/\/bjo.bmj.com\/content\/bjophthalmol\/81\/3\/184\/F2.medium.gif\u0022 width=\u0022440\u0022 height=\u0022289\u0022\/\u003E\u003Cnoscript\u003E\u003Cimg class=\u0022highwire-fragment fragment-image\u0022 alt=\u0022Figure 2\u0022 src=\u0022https:\/\/bjo.bmj.com\/content\/bjophthalmol\/81\/3\/184\/F2.medium.gif\u0022 width=\u0022440\u0022 height=\u0022289\u0022\/\u003E\u003C\/noscript\u003E\u003C\/span\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u0022download-fig first\u0022\u003E\u003Ca href=\u0022https:\/\/bjo.bmj.com\/content\/bjophthalmol\/81\/3\/184\/F2.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 2\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\n\u003Cli class=\u0022new-tab\u0022\u003E\u003Ca href=\u0022https:\/\/bjo.bmj.com\/content\/bjophthalmol\/81\/3\/184\/F2.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\n\u003Cli class=\u0022download-ppt last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/159821\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\n\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 2\u003C\/span\u003E \n\u003Cp id=\u0022p-16\u0022 class=\u0022first-child\u0022\u003ESpatula delamination. A fine spatula inserts rectilinearly into the hydrodelaminated stroma and comes back and is moved again and again fan-like in different directions.\u003C\/p\u003E\n\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n\u003Cp id=\u0022p-17\u0022\u003E\n\u003Cem\u003E(c) Exposure of Descemet\u2019s membrane\u003C\/em\u003E\u2003In thinner sections, anterior chamber pressure will cause a little bulging of the remaining stroma when the Descemet\u2019s membrane is close. Descemet\u2019s membrane is quite different from the stroma with its fibrous structure. It is a smooth and glossy membrane, and the difference is apparent immediately (see Fig \u003Ca id=\u0022xref-fig-3-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F3\u0022\u003E3\u003C\/a\u003E).\u003C\/p\u003E\n\u003Cdiv id=\u0022F3\u0022 class=\u0022fig pos-float\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022https:\/\/bjo.bmj.com\/content\/bjophthalmol\/81\/3\/184\/F3.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Descemet\u0026#x2019;s membrane is smooth and even, clearly distinguishable from the stroma.\u0022 class=\u0022highwire-fragment fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-1095093156\u0022 data-figure-caption=\u0022\u0026lt;div class=\u0026quot;highwire-markup\u0026quot;\u0026gt;Descemet\u0026#x2019;s membrane is smooth and even, clearly distinguishable from the stroma.\u0026lt;\/div\u0026gt;\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cspan class=\u0022hw-responsive-img\u0022\u003E\u003Cimg class=\u0022highwire-fragment fragment-image lazyload\u0022 alt=\u0022Figure 3\u0022 src=\u0022data:image\/gif;base64,R0lGODlhAQABAIAAAAAAAP\/\/\/yH5BAEAAAAALAAAAAABAAEAAAIBRAA7\u0022 data-src=\u0022https:\/\/bjo.bmj.com\/content\/bjophthalmol\/81\/3\/184\/F3.medium.gif\u0022 width=\u0022440\u0022 height=\u0022289\u0022\/\u003E\u003Cnoscript\u003E\u003Cimg class=\u0022highwire-fragment fragment-image\u0022 alt=\u0022Figure 3\u0022 src=\u0022https:\/\/bjo.bmj.com\/content\/bjophthalmol\/81\/3\/184\/F3.medium.gif\u0022 width=\u0022440\u0022 height=\u0022289\u0022\/\u003E\u003C\/noscript\u003E\u003C\/span\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u0022download-fig first\u0022\u003E\u003Ca href=\u0022https:\/\/bjo.bmj.com\/content\/bjophthalmol\/81\/3\/184\/F3.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 3\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\n\u003Cli class=\u0022new-tab\u0022\u003E\u003Ca href=\u0022https:\/\/bjo.bmj.com\/content\/bjophthalmol\/81\/3\/184\/F3.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\n\u003Cli class=\u0022download-ppt last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/159838\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\n\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 3\u003C\/span\u003E \n\u003Cp id=\u0022p-18\u0022 class=\u0022first-child\u0022\u003EDescemet\u2019s membrane is smooth and even, clearly distinguishable from the stroma.\u003C\/p\u003E\n\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n\u003Cp id=\u0022p-19\u0022\u003EDescemet\u2019s membrane adheres only loosely to the stroma, so that a spatula can be moved horizontally. If the remaining stroma is lifted with suturing forceps, it can be removed with corneal scissors over an area with a diameter of about 5 mm, covering the area of the pupil. Puncture can easily occur at this stage of the procedure, and delicate work is required. In addition, Descemet\u2019s membrane thickens with age, and can be fairly tough in the elderly. In the young, conversely, it is thin, and although elastic, is easily ruptured.\u003C\/p\u003E\n\u003Cp id=\u0022p-20\u0022\u003E\n\u003Cem\u003E(d) Puncturing Descemet\u2019s membrane\u003C\/em\u003E\u2003If Descemet\u2019s membrane is punctured during this procedure, and the hole is very small, the Descemet\u2019s membrane can be exposed by injecting air into the anterior chamber.\u003C\/p\u003E\n\u003Cp id=\u0022p-21\u0022\u003EIf there is extensive linear tearing, and stroma has been excised to an adequate depth, then removal of the stroma can be abandoned at this point and a start made on suturing the graft.\u003C\/p\u003E\n\n\n\u003Ch4\u003EPreparing the graft\u003C\/h4\u003E\n\u003Cp id=\u0022p-22\u0022\u003EFor 54 eyes, corneas were prepared by cryolathing from the endothelial side to a thickness of about 0.4 mm, and preserved by freezing before use. In 50 eyes, virtual full thickness grafts punched from the endothelial side after removal of Descemet\u2019s membrane with a cotton swab were used. For 16 eyes, fresh corneas with endothelial cells still attached were used.\u003C\/p\u003E\n\u003Cp id=\u0022p-23\u0022\u003EPostoperative transparency is achieved more quickly where fresh corneas are used, but over time the results are similar with corneas that have been frozen and preserved. A cornea preserved in glycerine was used in a single eye, and this graft had become very hard, making suturing difficult and causing problems with transparency postoperatively.\u003C\/p\u003E\n\n\n\u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-10\u0022\u003E\n\u003Ch2\u003EResults\u003C\/h2\u003E\n\u003Cp id=\u0022p-24\u0022\u003EIn 113 eyes observed for 6 months or more and in which average preoperative visual acuity was 0.09, average postoperative visual acuity improved to 0.6 (Fig \u003Ca id=\u0022xref-fig-4-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F4\u0022\u003E4\u003C\/a\u003E). In 71 of 113 eyes (62.8%), corrected postoperative visual acuity was 0.5 or better. There were 12 eyes in which corrected visual acuity was 0.1 or worse, but in nine of these, abnormalities were seen in the macular region.\u003C\/p\u003E\n\u003Cdiv id=\u0022F4\u0022 class=\u0022fig pos-float\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022https:\/\/bjo.bmj.com\/content\/bjophthalmol\/81\/3\/184\/F4.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Change of preoperative and postoperative visual acuity (87 eyes were followed up for more than 6 months).\u0022 class=\u0022highwire-fragment fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-1095093156\u0022 data-figure-caption=\u0022\u0026lt;div class=\u0026quot;highwire-markup\u0026quot;\u0026gt;Change of preoperative and postoperative visual acuity (87 eyes were followed up for more than 6 months).\u0026lt;\/div\u0026gt;\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cspan class=\u0022hw-responsive-img\u0022\u003E\u003Cimg class=\u0022highwire-fragment fragment-image lazyload\u0022 alt=\u0022Figure 4\u0022 src=\u0022data:image\/gif;base64,R0lGODlhAQABAIAAAAAAAP\/\/\/yH5BAEAAAAALAAAAAABAAEAAAIBRAA7\u0022 data-src=\u0022https:\/\/bjo.bmj.com\/content\/bjophthalmol\/81\/3\/184\/F4.medium.gif\u0022 width=\u0022440\u0022 height=\u0022402\u0022\/\u003E\u003Cnoscript\u003E\u003Cimg class=\u0022highwire-fragment fragment-image\u0022 alt=\u0022Figure 4\u0022 src=\u0022https:\/\/bjo.bmj.com\/content\/bjophthalmol\/81\/3\/184\/F4.medium.gif\u0022 width=\u0022440\u0022 height=\u0022402\u0022\/\u003E\u003C\/noscript\u003E\u003C\/span\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u0022download-fig first\u0022\u003E\u003Ca href=\u0022https:\/\/bjo.bmj.com\/content\/bjophthalmol\/81\/3\/184\/F4.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 4\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\n\u003Cli class=\u0022new-tab\u0022\u003E\u003Ca href=\u0022https:\/\/bjo.bmj.com\/content\/bjophthalmol\/81\/3\/184\/F4.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\n\u003Cli class=\u0022download-ppt last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/159849\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\n\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 4\u003C\/span\u003E \n\u003Cp id=\u0022p-25\u0022 class=\u0022first-child\u0022\u003EChange of preoperative and postoperative visual acuity (87 eyes were followed up for more than 6 months).\u003C\/p\u003E\n\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n\u003Cp id=\u0022p-26\u0022\u003EComparisons of postoperative visual acuity in five original pathologies are shown in Table \u003Ca id=\u0022xref-table-wrap-1-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T1\u0022\u003E1\u003C\/a\u003E. Gelatinous drop-like dystrophy showed statistically significant worse visual acuity than the others (granular dystrophy and lattice dystrophy; p\u0026lt;0.01, corneal leucoma and scarring; p\u0026lt;0.05, Tukey test).\u003C\/p\u003E\n\u003Cdiv class=\u0022table pos-float\u0022 id=\u0022T1\u0022\u003E\u003Cdiv class=\u0022table-inline table-callout-links\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u0022view-inline first\u0022\u003E\u003Ca href=\u0022##\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/159874\/expansion?postprocessors=highwire_tables%2Chighwire_reclass%2Chighwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\n\u003Cli class=\u0022view-popup last\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/159874\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_tables%2Chighwire_reclass%2Chighwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\n\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 1\u003C\/span\u003E \n\u003Cp id=\u0022p-27\u0022 class=\u0022first-child\u0022\u003EComparison of average visual acuity in five original pathologies\u003C\/p\u003E\n\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n\u003Cp id=\u0022p-29\u0022\u003ESpecular microscopy 1 month postoperatively revealed an average endothelial cell count of 2225 (SD 711)\/mm\u003Csup\u003E2\u003C\/sup\u003E, while 24 months postoperatively this value was 1937 (633)\/mm\u003Csup\u003E2\u003C\/sup\u003E (cell loss 13%).\u003C\/p\u003E\n\u003Cp id=\u0022p-30\u0022\u003EThere were 80 eyes in which Descemet\u2019s membrane alone constituted the optical zone. In 40 eyes, some parts of the deeper stromal lamellae were closer to normal, and hydrodelamination was abandoned at the point at which the stroma failed to swell, leaving some stroma remaining.\u003C\/p\u003E\n\u003Cp id=\u0022p-31\u0022\u003ETable \u003Ca id=\u0022xref-table-wrap-2-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T2\u0022\u003E2\u003C\/a\u003E compares corrected visual acuity and cell counts in these two groups at 12 months postoperatively. Both visual acuity and cell counts tended to be better where stroma remained, perhaps because the remaining stroma was close to normal and also became extremely thin, but statistically no difference was seen.\u003C\/p\u003E\n\u003Cdiv class=\u0022table pos-float\u0022 id=\u0022T2\u0022\u003E\u003Cdiv class=\u0022table-inline table-callout-links\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u0022view-inline first\u0022\u003E\u003Ca href=\u0022##\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/159877\/expansion?postprocessors=highwire_tables%2Chighwire_reclass%2Chighwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\n\u003Cli class=\u0022view-popup last\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/159877\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_tables%2Chighwire_reclass%2Chighwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\n\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 2\u003C\/span\u003E \n\u003Cp id=\u0022p-32\u0022 class=\u0022first-child\u0022\u003EComparison of visual acuity and cell count, at 12 months after surgery, between 80 eyes with Descemet\u2019s membrane exposed and 40 eyes with some stroma left during operation\u003C\/p\u003E\n\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n\u003Cp id=\u0022p-33\u0022\u003ETable \u003Ca id=\u0022xref-table-wrap-3-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T3\u0022\u003E3\u003C\/a\u003E compares eyes in which the donor cornea was cryolathed to a thickness of 0.4 mm from the endothelial side with eyes in which a full thickness cornea with Descemet\u2019s membrane only removed with a cotton swab or which included the endothelium were used.\u003C\/p\u003E\n\u003Cdiv class=\u0022table pos-float\u0022 id=\u0022T3\u0022\u003E\u003Cdiv class=\u0022table-inline table-callout-links\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u0022view-inline first\u0022\u003E\u003Ca href=\u0022##\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/159882\/expansion?postprocessors=highwire_tables%2Chighwire_reclass%2Chighwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\n\u003Cli class=\u0022view-popup last\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/159882\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_tables%2Chighwire_reclass%2Chighwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\n\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 3\u003C\/span\u003E \n\u003Cp id=\u0022p-34\u0022 class=\u0022first-child\u0022\u003EComparison of corneal thickness, visual acuity, and cell counts at 12 months postoperatively by difference between full thickness grafts and cryolathed grafts\u003C\/p\u003E\n\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n\u003Cp id=\u0022p-36\u0022\u003EPreoperatively, there was no difference in corneal thickness as measured with the pachymeter between the two groups. However, 12 months postoperatively, there had been a significant decrease in corneal thickness in the cryolathed group, at 453 (90) \u03bcm, as against 592 (57) \u03bcm in the full thickness group (p = 0.000, \u003Cem\u003Et\u003C\/em\u003E test).\u003C\/p\u003E\n\u003Cp id=\u0022p-37\u0022\u003ENo differences in postoperative visual acuity or in cell count were seen between the two groups at 12 months postoperatively.\u003C\/p\u003E\n\u003Cp id=\u0022p-38\u0022\u003EDescemet\u2019s membrane was punctured during surgery in 47 of 120 eyes (39.2%). This occurred in 37 of the first 80 eyes (45%), but fell to 10 in 40 eyes (25%) in later procedures. This was due to the fact that use of hydrodelamination became more widespread, but was not used unnecessarily where the deeper corneal stroma was close to normal, in which case some stroma was left.\u003C\/p\u003E\n\u003Cp id=\u0022p-39\u0022\u003EWhere Descemet\u2019s membrane had been punctured, anterior chamber aqueous may collect postoperatively at the interface between the graft and the recipient cornea to form a double anterior chamber. Oedema and opacification occur as a matter of course if grafts from which endothelial cells have been removed are used. A double anterior chamber was seen in 14 of 47 eyes (30%), but an injection of air into the anterior chamber eliminated the accumulated aqueous at the interface in all eyes, and all recovered.\u003C\/p\u003E\n\u003Cp id=\u0022p-40\u0022\u003EAmong 120 eyes, Descemet\u2019s membrane was punctured in 47 and remained intact in 73. No statistically significant difference was seen when these two groups were compared for visual acuity and cell counts 12 months postoperatively (Table \u003Ca id=\u0022xref-table-wrap-4-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T4\u0022\u003E4\u003C\/a\u003E). No statistically significant difference was seen between the 14 of 47 puncture eyes in which a double anterior chamber was seen postoperatively and the other 33 puncture eyes (Table \u003Ca id=\u0022xref-table-wrap-5-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T5\u0022\u003E5\u003C\/a\u003E).\u003C\/p\u003E\n\u003Cdiv class=\u0022table pos-float\u0022 id=\u0022T4\u0022\u003E\u003Cdiv class=\u0022table-inline table-callout-links\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u0022view-inline first\u0022\u003E\u003Ca href=\u0022##\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/159886\/expansion?postprocessors=highwire_tables%2Chighwire_reclass%2Chighwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\n\u003Cli class=\u0022view-popup last\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/159886\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_tables%2Chighwire_reclass%2Chighwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\n\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 4\u003C\/span\u003E \n\u003Cp id=\u0022p-41\u0022 class=\u0022first-child\u0022\u003EComparison of visual acuity and cell counts at 12 months postoperatively by presence of intraoperative puncture of Descemet\u2019s membrane\u003C\/p\u003E\n\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n\u003Cdiv class=\u0022table pos-float\u0022 id=\u0022T5\u0022\u003E\u003Cdiv class=\u0022table-inline table-callout-links\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u0022view-inline first\u0022\u003E\u003Ca href=\u0022##\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/159889\/expansion?postprocessors=highwire_tables%2Chighwire_reclass%2Chighwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\n\u003Cli class=\u0022view-popup last\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/159889\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_tables%2Chighwire_reclass%2Chighwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\n\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 5\u003C\/span\u003E \n\u003Cp id=\u0022p-42\u0022 class=\u0022first-child\u0022\u003EComparison of average visual acuity and cell counts at 12 months postoperatively by presence of double anterior chamber as the complication in 47 punctured eyes of Descemet\u2019s membrane\u003C\/p\u003E\n\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n\u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-11\u0022\u003E\n\u003Ch2\u003EDiscussion\u003C\/h2\u003E\n\u003Cp id=\u0022p-43\u0022\u003ELamellar keratoplasty has a number of advantages as a keratoplasty. No procedures are performed within the anterior chamber during surgery, so there is no postoperative intraocular complication such as anterior synechia of iris or secondary glaucoma. There is no endothelial rejection reaction and there is no need for the graft to have endothelial cells attached, so preserved corneas can be used. However, there is a decisive deficiency, which is that postoperative visual acuity is poor. LKP has, therefore, been regarded mainly as a therapeutic keratoplasty.\u003C\/p\u003E\n\u003Cp id=\u0022p-44\u0022\u003EThe cause of poor postoperative visual acuity is thought to be scarring which occurs at the interface between the donor cornea and the stroma of the recipient cornea, but this has not been established clearly in the literature.\u003C\/p\u003E\n\u003Cp id=\u0022p-45\u0022\u003EExperiments with DLK suggested that it was possible to obtain a marked improvement in postoperative visual acuity while retaining the advantages of LKP.\u003Ca id=\u0022xref-ref-1-1\u0022 class=\u0022xref-bibr\u0022 href=\u0022#ref-1\u0022\u003E1\u003C\/a\u003E In these eyes, pathological corneal stroma was completely excised so that Descemet\u2019s membrane was exposed at least in the region of the pupil, and donor corneas from which Descemet\u2019s membrane has been removed were used.\u003C\/p\u003E\n\u003Cp id=\u0022p-46\u0022\u003EDescemet\u2019s membrane is a basement membrane of uniform structure, whose thickness is thought to increase with age. Histologically it is quite thin, at about 10\u201313 \u03bcm in adults,\u003Ca id=\u0022xref-ref-2-1\u0022 class=\u0022xref-bibr\u0022 href=\u0022#ref-2\u0022\u003E2\u003C\/a\u003E\n\u003Ca id=\u0022xref-ref-3-1\u0022 class=\u0022xref-bibr\u0022 href=\u0022#ref-3\u0022\u003E3\u003C\/a\u003E and perhaps because it is thought to be very weak, there have been no reports on techniques that expose Descemet\u2019s membrane intentionally during surgery.\u003C\/p\u003E\n\u003Cp id=\u0022p-47\u0022\u003EHowever, if the effort is made to expose Descemet\u2019s membrane during surgery, and this exposed section is then extended, so that there is an area about 5 mm across including the area of the pupil where Descemet\u2019s membrane only is present, it will be found that there is practically no adhesion at this point between Descemet\u2019s membrane and the section where stroma remains.\u003C\/p\u003E\n\u003Cp id=\u0022p-48\u0022\u003EIf the endothelial side of the donor cornea is wiped with a cotton swab, Descemet\u2019s membrane can be ablated easily, leaving a completely smooth surface on the stromal side. The result is that no scar is formed at all at the interface between the host cornea, where Descemet\u2019s membrane only is present, and the donor cornea, from which Descemet\u2019s membrane has been removed. This is probably the reason that there is significant improvement in visual acuity postoperatively.\u003C\/p\u003E\n\u003Cp id=\u0022p-49\u0022\u003EAs for donor corneas, no difference was seen in average visual acuity 12 months postoperatively between a group in which virtually full thickness corneas with Descemet\u2019s membrane only removed or to which endothelial cells adhered, and a group in which corneas were cryolathed to a thickness of 0.4 mm. However, it was seen in the cryolathe group that, as might be expected, corneas were significantly thinner.\u003C\/p\u003E\n\u003Cp id=\u0022p-50\u0022\u003EA point worthy of note is that there was no endothelial rejection among 120 eyes. The condition considered to have the best prognosis after PKP is keratoconus. Of 72 eyes treated over the past 7 years (1988\u201395) at the Sugita Eye Hospital, all except one were maintained optically clear. However, in 55 eyes that were followed up more than 2 years after PKP, endothelial rejection has been seen in seven eyes (12.7%). Postoperative endothelial cell counts, examined in 48 eyes treated with PKP for keratoconus, continued to fall in a straight line over 2 years. By contrast, mean cell counts in 74 eyes treated with DLK tended to fall for the first 6 months postoperatively, but then stop (Fig \u003Ca id=\u0022xref-fig-5-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F5\u0022\u003E5\u003C\/a\u003E). Cell loss with DLK between the first month and 2 years postoperatively was 13%. After DLK the patient\u2019s own cells are active; when there is no danger of an endothelial rejection reaction, the cornea is very stable after keratoplasty.\u003C\/p\u003E\n\u003Cdiv id=\u0022F5\u0022 class=\u0022fig pos-float\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022https:\/\/bjo.bmj.com\/content\/bjophthalmol\/81\/3\/184\/F5.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Trend of decrease in postoperative endothelial cell counts, in 74 eyes that underwent deep lamellar keratoplasty(DLK) and 48 eyes that underwent penetrating keratoplasty (PKP) with keratoconus.\u0022 class=\u0022highwire-fragment fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-1095093156\u0022 data-figure-caption=\u0022\u0026lt;div class=\u0026quot;highwire-markup\u0026quot;\u0026gt;Trend of decrease in postoperative endothelial cell counts, in 74 eyes that underwent deep lamellar keratoplasty(DLK) and 48 eyes that underwent penetrating keratoplasty (PKP) with keratoconus.\u0026lt;\/div\u0026gt;\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cspan class=\u0022hw-responsive-img\u0022\u003E\u003Cimg class=\u0022highwire-fragment fragment-image lazyload\u0022 alt=\u0022Figure 5\u0022 src=\u0022data:image\/gif;base64,R0lGODlhAQABAIAAAAAAAP\/\/\/yH5BAEAAAAALAAAAAABAAEAAAIBRAA7\u0022 data-src=\u0022https:\/\/bjo.bmj.com\/content\/bjophthalmol\/81\/3\/184\/F5.medium.gif\u0022 width=\u0022364\u0022 height=\u0022440\u0022\/\u003E\u003Cnoscript\u003E\u003Cimg class=\u0022highwire-fragment fragment-image\u0022 alt=\u0022Figure 5\u0022 src=\u0022https:\/\/bjo.bmj.com\/content\/bjophthalmol\/81\/3\/184\/F5.medium.gif\u0022 width=\u0022364\u0022 height=\u0022440\u0022\/\u003E\u003C\/noscript\u003E\u003C\/span\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u0022download-fig first\u0022\u003E\u003Ca href=\u0022https:\/\/bjo.bmj.com\/content\/bjophthalmol\/81\/3\/184\/F5.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 5\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\n\u003Cli class=\u0022new-tab\u0022\u003E\u003Ca href=\u0022https:\/\/bjo.bmj.com\/content\/bjophthalmol\/81\/3\/184\/F5.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\n\u003Cli class=\u0022download-ppt last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/159860\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\n\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 5\u003C\/span\u003E \n\u003Cp id=\u0022p-51\u0022 class=\u0022first-child\u0022\u003ETrend of decrease in postoperative endothelial cell counts, in 74 eyes that underwent deep lamellar keratoplasty(DLK) and 48 eyes that underwent penetrating keratoplasty (PKP) with keratoconus.\u003C\/p\u003E\n\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n\u003Cp id=\u0022p-52\u0022\u003EFor corneal opacification for which surgery is indicated, examination of endothelial cell counts generally is unavailable preoperatively. Specular microscopy 6 months after DLK revealed that over 58% of the eyes had endothelial cell counts of more than 2000\/mm\u003Csup\u003E2\u003C\/sup\u003E. Fairly rich endothelial cells could be preserved with DLK; in contrast, in PKP, endothelial cells could be totally replaced with the donor\u2019s cells.\u003C\/p\u003E\n\u003Cp id=\u0022p-53\u0022\u003EGelatinous drop-like dystrophy showed significantly worse postoperative visual acuity within five original pathologies. Gelatinous drop-like dystrophy is chiefly affected corneal epithelium and Bowman\u2019s layer and recurred in transplanted grafts. This recurrence could be protected against by using a combined procedure with keratoepithelioplasty\u003Ca id=\u0022xref-ref-4-1\u0022 class=\u0022xref-bibr\u0022 href=\u0022#ref-4\u0022\u003E4\u003C\/a\u003E or conjunctival autograft and also using a therapeutic soft contact lens thereafter.\u003C\/p\u003E\n\u003Cp id=\u0022p-54\u0022\u003ETo date, there have been few reports on DLK\u003Ca id=\u0022xref-ref-1-2\u0022 class=\u0022xref-bibr\u0022 href=\u0022#ref-1\u0022\u003E1\u003C\/a\u003E\n\u003Ca id=\u0022xref-ref-5-1\u0022 class=\u0022xref-bibr\u0022 href=\u0022#ref-5\u0022\u003E5\u003C\/a\u003E\n\u003Ca id=\u0022xref-ref-8-1\u0022 class=\u0022xref-bibr\u0022 href=\u0022#ref-8\u0022\u003E8\u003C\/a\u003Eespecially on complete stromal excision exposing Descemet\u2019s membrane, because surgical techniques for DLK are considered to be difficult.\u003C\/p\u003E\n\u003Cp id=\u0022p-55\u0022\u003EThe new technique uses hydrodelamination in which a saline solution is injected into the deep stroma to swell stromal collagen fibres, and spatula delamination in which a thin 0.25 mm diameter spatula is employed. Thus, complete excision of pathological stroma is possible to limit the optical zone to Descemet\u2019s membrane only, minimising the risk of puncture of Descemet\u2019s membrane.\u003C\/p\u003E\n\u003Cp id=\u0022p-56\u0022\u003EA previous report described stromal excision by utilising air injected into the stroma.\u003Ca id=\u0022xref-ref-7-1\u0022 class=\u0022xref-bibr\u0022 href=\u0022#ref-7\u0022\u003E7\u003C\/a\u003E\n\u003Ca id=\u0022xref-ref-8-2\u0022 class=\u0022xref-bibr\u0022 href=\u0022#ref-8\u0022\u003E8\u003C\/a\u003E This method is only possible when the stroma maintains its consistency. If the stromal layer is thin, this method is not applicable. Transparency of the stroma is lost by injecting air, thus preventing visibility of collagen fibres.\u003C\/p\u003E\n\u003Cp id=\u0022p-57\u0022\u003EWith hydrodelamination, a saline solution is injected to swell the thin stroma to make it thick enough to allow further excision. The stroma is temporarily opacified by the injected solution, but it does not prevent identification of collagen fibres. Further, by observing how the solution penetrates into the stroma, one can determine the density of the stromal collagen fibres and whether the stroma is nearly normal or not. If the stroma is nearly normal, the solution spreads in all directions, and the stroma whitens and swells (Fig \u003Ca id=\u0022xref-fig-1-2\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003E1\u003C\/a\u003E). In pathological stroma, where the structure of collagen fibres is lost and scarred, the solution cannot penetrate into the stroma and there is very little whitening and swelling. Such pathological stroma should be excised completely to leave only Descemet\u2019s membrane. If the deep stroma is close to normal, excision should be stopped at the point where the stroma does not swell any more with hydrodelamination, leaving a small portion of the stroma unexcised.\u003C\/p\u003E\n\u003Cp id=\u0022p-58\u0022\u003EOf 120 eyes, 80 had Descemet\u2019s membrane exposed and 40 had some portion of the stroma left intraoperatively. Average visual acuity and endothelial cell counts were compared between these two groups 12 months postoperatively. Leaving a small amount of stroma did not produce any difference in visual acuity as long as the deeper stroma is fairly normal. Any puncture occurring during surgery puts surgeons under considerable stress; so, leaving a small amount of stroma is recommended. In this case, however, it is essential that hydrodelamination spreads the solution evenly in the stroma and that the stroma is excised deeply enough to the extent that it does not swell any more with the injected solution.\u003C\/p\u003E\n\u003Cp id=\u0022p-59\u0022\u003EFresh donor corneas offer earlier recovery of postoperative visual acuity. However, 3 months postoperatively and thereafter, visual acuity obtained with stored frozen corneas is comparable with that obtained with fresh corneas.\u003C\/p\u003E\n\u003Cp id=\u0022p-60\u0022\u003EPuncture in Descemet\u2019s membrane is an intraoperative complication. This might occur when surgeons try to limit the optical zone to only Descemet\u2019s membrane, because any portion of pathological stroma, if unexcised, may result in poor visual outcome, which is almost inevitable with the current surgical procedure. There are two methods of dealing with this. If the hole is small, air is injected into the anterior chamber and a graft is sutured on. If the hole is large, further excision of the stroma is abandoned and a graft is sutured, then air is injected into the anterior chamber. Care should be taken if a viscoelastic material is used, because there is risk of entrapment of the viscoelastic material between Descemet\u2019s membrane and the graft, and its absorption might be considerably delayed. As an alternative, when a puncture does occur one can switch to PKP, but all the 47 eyes in this report were treated with DLK.\u003C\/p\u003E\n\u003Cp id=\u0022p-61\u0022\u003EFormation of a double anterior chamber was observed as a postoperative complication in 14 eyes (30%) out of 47 eyes in which Descemet\u2019s membrane was punctured during operation. The graft, without endothelial cells, will develop oedema like primary graft failure. If the double anterior chamber does not disappear after a few days, it is necessary to inject additional air into the anterior chamber and to drain the collected aqueous humour from the space of the double anterior chamber. Because of multiple interventions, in these eyes there was a tendency towards a decrease in endothelial cell counts but statistically no difference was found between the \u2018presence of double anterior chamber\u2019 group and \u2018non-presence group\u2019 at 12 months postoperatively. Also, there was no difference in visual acuity between two groups. If the donor corneas are fresh and with endothelial cells, the grafts can survive as usual PKP even though a double anterior chamber is formed.\u003C\/p\u003E\n\u003Cp id=\u0022p-62\u0022\u003EThe success rate of PKP is rising year by year. However, endothelial cells continue to reduce at a considerable speed even 5 years after surgery\u003Ca id=\u0022xref-ref-9-1\u0022 class=\u0022xref-bibr\u0022 href=\u0022#ref-9\u0022\u003E9\u003C\/a\u003E), and a long term reduction over 10 or 15 years often results in a relapse of opacification due to decompensation of endothelial cells.\u003C\/p\u003E\n\u003Cp id=\u0022p-63\u0022\u003EDeep lamellar keratoplasty should be used more frequently because it offers satisfactory visual outcome and stability for a longer period of time, but if it is only possible to remove pathological stroma totally.\u003C\/p\u003E\n\u003C\/div\u003E\u003Cdiv class=\u0022section ack\u0022 id=\u0022ack-1\u0022\u003E\u003Ch2\u003EAcknowledgments\u003C\/h2\u003E\n\u003Cp id=\u0022p-64\u0022\u003EThis study was supported in part from a grant by Aichi Eye Bank.\u003C\/p\u003E\n\u003C\/div\u003E\u003Cdiv class=\u0022section ref-list\u0022 id=\u0022ref-list-1\u0022\u003E\u003Ch2\u003EReferences\u003C\/h2\u003E\u003Col class=\u0022cit-list\u0022\u003E\u003Cli\u003E\u003Ca class=\u0022rev-xref-ref\u0022 href=\u0022#xref-ref-1-1\u0022 title=\u0022View reference 1 in text\u0022 id=\u0022ref-1\u0022\u003E\u21b5\u003C\/a\u003E\n\u003Cdiv class=\u0022cit ref-cit ref-journal\u0022 id=\u0022cit-81.3.184.1\u0022\u003E\u003Cdiv class=\u0022cit-metadata\u0022\u003E\u003Col class=\u0022cit-auth-list\u0022\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\u003Cspan class=\u0022cit-name-surname\u0022\u003ESugita\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003EJ\u003C\/span\u003E\u003C\/span\u003E, \u003C\/li\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\u003Cspan class=\u0022cit-name-surname\u0022\u003EKondo\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003EJ\u003C\/span\u003E\u003C\/span\u003E\u003C\/li\u003E\u003C\/ol\u003E\u003Ccite\u003E(\u003Cspan class=\u0022cit-pub-date\u0022\u003E1994\u003C\/span\u003E) \u003Cspan class=\u0022cit-article-title\u0022\u003ELamellar keratoplasty and deep lamellar keratoplasty.\u003C\/span\u003E \u003Cabbr class=\u0022cit-jnl-abbrev\u0022\u003EFolia Ophthalmol Jpn\u003C\/abbr\u003E \u003Cspan class=\u0022cit-vol\u0022\u003E45\u003C\/span\u003E:\u003Cspan class=\u0022cit-fpage\u0022\u003E1\u003C\/span\u003E\u2013\u003Cspan class=\u0022cit-lpage\u0022\u003E3\u003C\/span\u003E.\u003C\/cite\u003E\u003C\/div\u003E\u003Cdiv class=\u0022cit-extra\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\n\u003C\/li\u003E\u003Cli\u003E\u003Ca class=\u0022rev-xref-ref\u0022 href=\u0022#xref-ref-2-1\u0022 title=\u0022View reference 2 in text\u0022 id=\u0022ref-2\u0022\u003E\u21b5\u003C\/a\u003E\n\u003Cdiv class=\u0022cit ref-cit ref-other\u0022 id=\u0022cit-81.3.184.2\u0022\u003E\u003Cdiv class=\u0022cit-metadata\u0022\u003E\u003Col class=\u0022cit-auth-list\u0022\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\u003Cspan class=\u0022cit-name-surname\u0022\u003EHogan\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003EMJ\u003C\/span\u003E\u003C\/span\u003E, \u003C\/li\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\u003Cspan class=\u0022cit-name-surname\u0022\u003EAlvalado\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003EJA\u003C\/span\u003E\u003C\/span\u003E, \u003C\/li\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\u003Cspan class=\u0022cit-name-surname\u0022\u003EWedell\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003EJE\u003C\/span\u003E\u003C\/span\u003E\u003C\/li\u003E\u003C\/ol\u003E\u003Ccite\u003E(\u003Cspan class=\u0022cit-pub-date\u0022\u003E1971\u003C\/span\u003E) \u003Cspan class=\u0022cit-source\u0022\u003EHistology of the human eye .\u003C\/span\u003E (\u003Cspan class=\u0022cit-publ-name\u0022\u003ESaunders\u003C\/span\u003E, \u003Cspan class=\u0022cit-publ-loc\u0022\u003EPhiladelphia\u003C\/span\u003E), pp \u003Cspan class=\u0022cit-fpage\u0022\u003E93\u003C\/span\u003E\u2013\u003Cspan class=\u0022cit-lpage\u0022\u003E102\u003C\/span\u003E.\u003C\/cite\u003E\u003C\/div\u003E\u003Cdiv class=\u0022cit-extra\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\n\u003C\/li\u003E\u003Cli\u003E\u003Ca class=\u0022rev-xref-ref\u0022 href=\u0022#xref-ref-3-1\u0022 title=\u0022View reference 3 in text\u0022 id=\u0022ref-3\u0022\u003E\u21b5\u003C\/a\u003E\n\u003Cdiv class=\u0022cit ref-cit ref-other\u0022 id=\u0022cit-81.3.184.3\u0022\u003E\u003Cdiv class=\u0022cit-metadata\u0022\u003E\u003Col class=\u0022cit-ed-list duplicate\u0022\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-ed\u0022\u003E\u003Cspan class=\u0022cit-name-surname\u0022\u003ESmolin\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003EG\u003C\/span\u003E\u003C\/span\u003E, \u003C\/li\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-ed\u0022\u003E\u003Cspan class=\u0022cit-name-surname\u0022\u003EThoft\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003ERA\u003C\/span\u003E\u003C\/span\u003E\u003C\/li\u003E\u003C\/ol\u003E\u003Col class=\u0022cit-auth-list\u0022\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\u003Cspan class=\u0022cit-name-surname\u0022\u003EGipson\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003EIK\u003C\/span\u003E\u003C\/span\u003E\u003C\/li\u003E\u003C\/ol\u003E\u003Ccite\u003E(\u003Cspan class=\u0022cit-pub-date\u0022\u003E1994\u003C\/span\u003E) \u003Cspan class=\u0022cit-article-title\u0022\u003EAnatomy of the conjunctiva, cornea, and limbus.\u003C\/span\u003E in \u003Cspan class=\u0022cit-source\u0022\u003EThe cornea: scientific foundations and clinical practice .\u003C\/span\u003E eds \u003Cspan class=\u0022cit-ed\u0022\u003E\u003Cspan class=\u0022cit-name-surname\u0022\u003ESmolin\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003EG\u003C\/span\u003E\u003C\/span\u003E, \u003Cspan class=\u0022cit-ed\u0022\u003E\u003Cspan class=\u0022cit-name-surname\u0022\u003EThoft\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003ERA\u003C\/span\u003E\u003C\/span\u003E(\u003Cspan class=\u0022cit-publ-name\u0022\u003ELittle, Brown\u003C\/span\u003E, \u003Cspan class=\u0022cit-publ-loc\u0022\u003EBoston\u003C\/span\u003E), \u003Cspan class=\u0022cit-edition\u0022\u003E3rd ed.\u003C\/span\u003E pp \u003Cspan class=\u0022cit-fpage\u0022\u003E3\u003C\/span\u003E\u2013\u003Cspan class=\u0022cit-lpage\u0022\u003E24\u003C\/span\u003E.\u003C\/cite\u003E\u003C\/div\u003E\u003Cdiv class=\u0022cit-extra\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\n\u003C\/li\u003E\u003Cli\u003E\u003Ca class=\u0022rev-xref-ref\u0022 href=\u0022#xref-ref-4-1\u0022 title=\u0022View reference 4 in text\u0022 id=\u0022ref-4\u0022\u003E\u21b5\u003C\/a\u003E\n\u003Cdiv class=\u0022cit ref-cit ref-journal\u0022 id=\u0022cit-81.3.184.4\u0022\u003E\u003Cdiv class=\u0022cit-metadata\u0022\u003E\u003Col class=\u0022cit-auth-list\u0022\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\u003Cspan class=\u0022cit-name-surname\u0022\u003EOhashi\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003EY\u003C\/span\u003E\u003C\/span\u003E, \u003C\/li\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\u003Cspan class=\u0022cit-name-surname\u0022\u003EKinoshita\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003ES\u003C\/span\u003E\u003C\/span\u003E, \u003C\/li\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\u003Cspan class=\u0022cit-name-surname\u0022\u003EHosotani\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003EH\u003C\/span\u003E\u003C\/span\u003E, \u003C\/li\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\u003Cspan class=\u0022cit-name-surname\u0022\u003EWatanabe\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003EK\u003C\/span\u003E\u003C\/span\u003E, \u003C\/li\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\u003Cspan class=\u0022cit-name-surname\u0022\u003EWatanabe\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003EH\u003C\/span\u003E\u003C\/span\u003E, \u003C\/li\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\u003Cspan class=\u0022cit-name-surname\u0022\u003EHagihira\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003EY\u003C\/span\u003E\u003C\/span\u003E, \u003C\/li\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-etal\u0022\u003Eet al.\u003C\/span\u003E\u003C\/li\u003E\u003C\/ol\u003E\u003Ccite\u003E(\u003Cspan class=\u0022cit-pub-date\u0022\u003E1991\u003C\/span\u003E) \u003Cspan class=\u0022cit-article-title\u0022\u003ENew surgical strategy for gelatinous drop-like corneal dystrophy.\u003C\/span\u003E \u003Cabbr class=\u0022cit-jnl-abbrev\u0022\u003EJpn J Clin Ophthalmol (Rinsho Ganka)\u003C\/abbr\u003E \u003Cspan class=\u0022cit-vol\u0022\u003E45\u003C\/span\u003E:\u003Cspan class=\u0022cit-fpage\u0022\u003E523\u003C\/span\u003E\u2013\u003Cspan class=\u0022cit-lpage\u0022\u003E526\u003C\/span\u003E.\u003C\/cite\u003E\u003C\/div\u003E\u003Cdiv class=\u0022cit-extra\u0022\u003E\u003Ca href=\u0022{openurl}?query=rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-openurl cit-ref-sprinkles-open-url\u0022\u003E\u003Cspan\u003EOpenUrl\u003C\/span\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\n\u003C\/li\u003E\u003Cli\u003E\u003Ca class=\u0022rev-xref-ref\u0022 href=\u0022#xref-ref-5-1\u0022 title=\u0022View reference 5 in text\u0022 id=\u0022ref-5\u0022\u003E\u21b5\u003C\/a\u003E\n\u003Cdiv class=\u0022cit ref-cit ref-journal\u0022 id=\u0022cit-81.3.184.5\u0022\u003E\u003Cdiv class=\u0022cit-metadata\u0022\u003E\u003Col class=\u0022cit-auth-list\u0022\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\u003Cspan class=\u0022cit-name-surname\u0022\u003ETomita\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003ET\u003C\/span\u003E\u003C\/span\u003E, \u003C\/li\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\u003Cspan class=\u0022cit-name-surname\u0022\u003ESakimoto\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003ET\u003C\/span\u003E\u003C\/span\u003E, \u003C\/li\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\u003Cspan class=\u0022cit-name-surname\u0022\u003EIto\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003EH\u003C\/span\u003E\u003C\/span\u003E\u003C\/li\u003E\u003C\/ol\u003E\u003Ccite\u003E(\u003Cspan class=\u0022cit-pub-date\u0022\u003E1986\u003C\/span\u003E) \u003Cspan class=\u0022cit-article-title\u0022\u003EClinical study of deep lamellar keratoplasty.\u003C\/span\u003E \u003Cabbr class=\u0022cit-jnl-abbrev\u0022\u003EJ Eye (Atarasiiganka)\u003C\/abbr\u003E \u003Cspan class=\u0022cit-vol\u0022\u003E3\u003C\/span\u003E:\u003Cspan class=\u0022cit-fpage\u0022\u003E113\u003C\/span\u003E\u2013\u003Cspan class=\u0022cit-lpage\u0022\u003E116\u003C\/span\u003E.\u003C\/cite\u003E\u003C\/div\u003E\u003Cdiv class=\u0022cit-extra\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\n\u003C\/li\u003E\u003Cli\u003E\n\u003Cdiv class=\u0022cit ref-cit ref-journal no-rev-xref\u0022 id=\u0022cit-81.3.184.6\u0022\u003E\u003Cdiv class=\u0022cit-metadata\u0022\u003E\u003Col class=\u0022cit-auth-list\u0022\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\u003Cspan class=\u0022cit-name-surname\u0022\u003EKondo\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003EJ\u003C\/span\u003E\u003C\/span\u003E, \u003C\/li\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\u003Cspan class=\u0022cit-name-surname\u0022\u003ESugita\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003EJ\u003C\/span\u003E\u003C\/span\u003E\u003C\/li\u003E\u003C\/ol\u003E\u003Ccite\u003E(\u003Cspan class=\u0022cit-pub-date\u0022\u003E1992\u003C\/span\u003E) \u003Cspan class=\u0022cit-article-title\u0022\u003EDeep lamellar keratoplasty.\u003C\/span\u003E \u003Cabbr class=\u0022cit-jnl-abbrev\u0022\u003EJ Eye (Atarasiiganka)\u003C\/abbr\u003E \u003Cspan class=\u0022cit-vol\u0022\u003E9\u003C\/span\u003E:\u003Cspan class=\u0022cit-fpage\u0022\u003E2061\u003C\/span\u003E\u2013\u003Cspan class=\u0022cit-lpage\u0022\u003E2064\u003C\/span\u003E.\u003C\/cite\u003E\u003C\/div\u003E\u003Cdiv class=\u0022cit-extra\u0022\u003E\u003Ca href=\u0022{openurl}?query=rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-openurl cit-ref-sprinkles-open-url\u0022\u003E\u003Cspan\u003EOpenUrl\u003C\/span\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\n\u003C\/li\u003E\u003Cli\u003E\u003Ca class=\u0022rev-xref-ref\u0022 href=\u0022#xref-ref-7-1\u0022 title=\u0022View reference 7 in text\u0022 id=\u0022ref-7\u0022\u003E\u21b5\u003C\/a\u003E\n\u003Cdiv class=\u0022cit ref-cit ref-journal\u0022 id=\u0022cit-81.3.184.7\u0022\u003E\u003Cdiv class=\u0022cit-metadata\u0022\u003E\u003Col class=\u0022cit-auth-list\u0022\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\u003Cspan class=\u0022cit-name-surname\u0022\u003EArchila\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003EEA\u003C\/span\u003E\u003C\/span\u003E\u003C\/li\u003E\u003C\/ol\u003E\u003Ccite\u003E(\u003Cspan class=\u0022cit-pub-date\u0022\u003E1985\u003C\/span\u003E) \u003Cspan class=\u0022cit-article-title\u0022\u003EDeep lamellar keratoplasty dissection of host tissue with intrastromal air injection.\u003C\/span\u003E \u003Cabbr class=\u0022cit-jnl-abbrev\u0022\u003ECornea\u003C\/abbr\u003E \u003Cspan class=\u0022cit-vol\u0022\u003E3\u003C\/span\u003E:\u003Cspan class=\u0022cit-fpage\u0022\u003E217\u003C\/span\u003E\u2013\u003Cspan class=\u0022cit-lpage\u0022\u003E218\u003C\/span\u003E.\u003C\/cite\u003E\u003C\/div\u003E\u003Cdiv class=\u0022cit-extra\u0022\u003E\u003Ca href=\u0022{openurl}?query=rft.jtitle%253DCornea%26rft.stitle%253DCornea%26rft.aulast%253DArchila%26rft.auinit1%253DE.%2BA.%26rft.volume%253D3%26rft.issue%253D3%26rft.spage%253D217%26rft.epage%253D218%26rft.atitle%253DDeep%2Blamellar%2Bkeratoplasty%2Bdissection%2Bof%2Bhost%2Btissue%2Bwith%2Bintrastromal%2Bair%2Binjection.%26rft_id%253Dinfo%253Apmid%252F6399886%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-openurl cit-ref-sprinkles-open-url\u0022\u003E\u003Cspan\u003EOpenUrl\u003C\/span\u003E\u003C\/a\u003E\u003Ca href=\u0022\/lookup\/external-ref?access_num=6399886\u0026amp;link_type=MED\u0026amp;atom=%2Fbjophthalmol%2F81%2F3%2F184.atom\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-medline\u0022\u003E\u003Cspan\u003EPubMed\u003C\/span\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\n\u003C\/li\u003E\u003Cli\u003E\u003Ca class=\u0022rev-xref-ref\u0022 href=\u0022#xref-ref-8-1\u0022 title=\u0022View reference 8 in text\u0022 id=\u0022ref-8\u0022\u003E\u21b5\u003C\/a\u003E\n\u003Cdiv class=\u0022cit ref-cit ref-journal\u0022 id=\u0022cit-81.3.184.8\u0022 data-doi=\u002210.1136\/bjo.76.11.646\u0022\u003E\u003Cdiv class=\u0022cit-metadata\u0022\u003E\u003Col class=\u0022cit-auth-list\u0022\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\u003Cspan class=\u0022cit-name-surname\u0022\u003EChau\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003EGK\u003C\/span\u003E\u003C\/span\u003E, \u003C\/li\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\u003Cspan class=\u0022cit-name-surname\u0022\u003EDilly\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003ESA\u003C\/span\u003E\u003C\/span\u003E, \u003C\/li\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\u003Cspan class=\u0022cit-name-surname\u0022\u003ESheard\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003ECE\u003C\/span\u003E\u003C\/span\u003E, \u003C\/li\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\u003Cspan class=\u0022cit-name-surname\u0022\u003ERostron\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003ECK\u003C\/span\u003E\u003C\/span\u003E\u003C\/li\u003E\u003C\/ol\u003E\u003Ccite\u003E(\u003Cspan class=\u0022cit-pub-date\u0022\u003E1992\u003C\/span\u003E) \u003Cspan class=\u0022cit-article-title\u0022\u003EDeep lamellar keratoplasty on air with lyophilized tissue.\u003C\/span\u003E \u003Cabbr class=\u0022cit-jnl-abbrev\u0022\u003EBr J Ophthalmol\u003C\/abbr\u003E \u003Cspan class=\u0022cit-vol\u0022\u003E76\u003C\/span\u003E:\u003Cspan class=\u0022cit-fpage\u0022\u003E646\u003C\/span\u003E\u2013\u003Cspan class=\u0022cit-lpage\u0022\u003E650\u003C\/span\u003E.\u003C\/cite\u003E\u003C\/div\u003E\u003Cdiv class=\u0022cit-extra\u0022\u003E\u003Ca href=\u0022{openurl}?query=rft.jtitle%253DBritish%2BJournal%2Bof%2BOphthalmology%26rft.stitle%253DBr%2BJ%2BOphthalmol%26rft.issn%253D0007-1161%26rft.aulast%253DChau%26rft.auinit1%253DG%2BK%26rft.volume%253D76%26rft.issue%253D11%26rft.spage%253D646%26rft.epage%253D650%26rft.atitle%253DDeep%2Blamellar%2Bkeratoplasty%2Bon%2Bair%2Bwith%2Blyophilised%2Btissue.%26rft_id%253Dinfo%253Adoi%252F10.1136%252Fbjo.76.11.646%26rft_id%253Dinfo%253Apmid%252F1477037%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-openurl cit-ref-sprinkles-open-url\u0022\u003E\u003Cspan\u003EOpenUrl\u003C\/span\u003E\u003C\/a\u003E\u003Ca href=\u0022\/lookup\/ijlink\/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6MTI6ImJqb3BodGhhbG1vbCI7czo1OiJyZXNpZCI7czo5OiI3Ni8xMS82NDYiO3M6NDoiYXRvbSI7czoyNzoiL2Jqb3BodGhhbG1vbC84MS8zLzE4NC5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-ijlink\u0022\u003E\u003Cspan\u003E\u003Cspan class=\u0022cit-reflinks-abstract\u0022\u003EAbstract\u003C\/span\u003E\u003Cspan class=\u0022cit-sep cit-reflinks-variant-name-sep\u0022\u003E\/\u003C\/span\u003E\u003Cspan class=\u0022cit-reflinks-full-text\u0022\u003E\u003Cspan class=\u0022free-full-text\u0022\u003EFREE \u003C\/span\u003EFull Text\u003C\/span\u003E\u003C\/span\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\n\u003C\/li\u003E\u003Cli\u003E\u003Ca class=\u0022rev-xref-ref\u0022 href=\u0022#xref-ref-9-1\u0022 title=\u0022View reference 9 in text\u0022 id=\u0022ref-9\u0022\u003E\u21b5\u003C\/a\u003E\n\u003Cdiv class=\u0022cit ref-cit ref-journal\u0022 id=\u0022cit-81.3.184.9\u0022\u003E\u003Cdiv class=\u0022cit-metadata\u0022\u003E\u003Col class=\u0022cit-auth-list\u0022\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\u003Cspan class=\u0022cit-name-surname\u0022\u003EBourne\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003EWM\u003C\/span\u003E\u003C\/span\u003E, \u003C\/li\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\u003Cspan class=\u0022cit-name-surname\u0022\u003EHodge\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003EDO\u003C\/span\u003E\u003C\/span\u003E, \u003C\/li\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\u003Cspan class=\u0022cit-name-surname\u0022\u003ENelson\u003C\/span\u003E \u003Cspan class=\u0022cit-name-given-names\u0022\u003EBA\u003C\/span\u003E\u003C\/span\u003E\u003C\/li\u003E\u003C\/ol\u003E\u003Ccite\u003E(\u003Cspan class=\u0022cit-pub-date\u0022\u003E1994\u003C\/span\u003E) \u003Cspan class=\u0022cit-article-title\u0022\u003ECorneal endothelium five years after transplantation.\u003C\/span\u003E \u003Cabbr class=\u0022cit-jnl-abbrev\u0022\u003EAm J Ophthalmol\u003C\/abbr\u003E \u003Cspan class=\u0022cit-vol\u0022\u003E118\u003C\/span\u003E:\u003Cspan class=\u0022cit-fpage\u0022\u003E185\u003C\/span\u003E\u2013\u003Cspan class=\u0022cit-lpage\u0022\u003E196\u003C\/span\u003E.\u003C\/cite\u003E\u003C\/div\u003E\u003Cdiv class=\u0022cit-extra\u0022\u003E\u003Ca href=\u0022{openurl}?query=rft.jtitle%253DAmerican%2Bjournal%2Bof%2Bophthalmology%26rft.stitle%253DAm%2BJ%2BOphthalmol%26rft.aulast%253DBourne%26rft.auinit1%253DW.%2BM.%26rft.volume%253D118%26rft.issue%253D2%26rft.spage%253D185%26rft.epage%253D196%26rft.atitle%253DCorneal%2Bendothelium%2Bfive%2Byears%2Bafter%2Btransplantation.%26rft_id%253Dinfo%253Apmid%252F8053464%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-openurl cit-ref-sprinkles-open-url\u0022\u003E\u003Cspan\u003EOpenUrl\u003C\/span\u003E\u003C\/a\u003E\u003Ca href=\u0022\/lookup\/external-ref?access_num=8053464\u0026amp;link_type=MED\u0026amp;atom=%2Fbjophthalmol%2F81%2F3%2F184.atom\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-medline\u0022\u003E\u003Cspan\u003EPubMed\u003C\/span\u003E\u003C\/a\u003E\u003Ca href=\u0022\/lookup\/external-ref?access_num=A1994PA91000006\u0026amp;link_type=ISI\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-newisilink cit-ref-sprinkles-webofscience\u0022\u003E\u003Cspan\u003EWeb of Science\u003C\/span\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\n\u003C\/li\u003E\u003C\/ol\u003E\u003C\/div\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022https:\/\/bjo.bmj.com\/content\/81\/3\/184.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Abstract\u003C\/a\u003E\u003C\/div\u003E \u003C\/div\u003E\n\n \n \u003C\/div\u003E\n\u003Cdiv class=\u0022panel-separator\u0022\u003E\u003C\/div\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup footnotes\u0022 \u003E\n \n \n \n \u003Cdiv 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